HomeMy WebLinkAbout020-1317-40-000
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AS BUILT SANITARY SYSTEM REPORT
OWNER_ -ITM RUSCh \C~21S KObI~ ke
ADDRESS SUn1R~DGe
SUBDIVISION / CSM# LOT # S 9
SECTION Qy T a9 N-R 19 W, Town of I VDS,N
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
NOte ; ry)Any W COU PK ov P9
y'
y
Yap
Q 970
No►ti,Q y(~~
3 I4wr es
Sx
GO'
0
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
WAS 83.4b M6 hl N ~
~P W{►1,~
Wb ~ S I tN ►~v B~~~fC ~ IN
T I ~ MUM 1r?f RA►S~d g►~.
_49- •7 0 .
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W e~~-S Liquid Capacity: I o~ UU P
Setback from: Well oven House 37' Other yU
Pump: Manufacturer Model# f, Size
Float seperation ----1 Gallons/cycle: i,
Alarm Location
SOIL ABSORPTION SYSTEM
Was $0.00 Width: S Length Number of trenches 3
RoIrep 11" Distance & Direction to nearest prop. line: Is
Setback from: wel 1 : o,jer Sd House O' Other G S
1'r T 4,11
14eproa, m%D t~eeup~ 6.),01 Hewo2 83.0% if 81.00 9134'q
FNo ~9•c,l 5,N 8181 fNn 8a.$(0
® ~~,$~_9a g, ,w U.0o LEVATIONS 000P- 8? SS
f3~llarr 7g•4b Building Sewer ST Inlet.
9 ST outlet
WeS 7$.Up
(Zo's~b PC inlet PC bottom Pump Off
trti ` M H
S~3'
B
Bottom of system
Existing Grade 5AIv~ Final grade COW
8y.sa SS•(~p
DATE OF INSTALLATION: I 19~p
PLUMBER ON JOB: Qom,` BOR.f!)r~e
LICENSE NUMBER: 3 y0 y
INSPECTOR:
3 / 9 3 : j t
JVisconsin'bepartmentofIndustry, PRIVATE SEWAGE SYSTEM County:
Labbr and Human Relations INSPECTION REPORT ST. CROIX
. Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
PiWdn jI-jnWgr~rlime~HRiS ❑ City ❑ Village Town of: State Plan I o.:
CST BM Elev.: L; Insp. BM Elev.: BM Description: Parcel Tax No.:
/0~) "
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer -
Holding St/ Ht Inlet c~58' ~,14r'
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic y 6-' , So NA Dt Bottom
Dosing NA Header/Man. 't -
Aeration NA Dist. Pipe 92-' 01,
Holding Bot. System a ys. 72
PUMP/ SIPHON INFORMATION Final Grade s.~. ss
2 5• v
Manufacturer Demand
Model Number GPM
TDH Lift `riction System TDH Ft
oss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION cS` 6. 7, DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O Model Number:
System: t1Nt.cA. _5 ' U OR UNIT
DISTRIBUTION SYSTEM
Header/ Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.24.29.19W, SE, NE, YOUNG ROAD
Plan revision required? ❑ Yes [ /No
Use other side for additional information. 9~ (c d
SBD-6710 (R 05/91) Date In pe or's Signature Cert. No.
SANITARY PERMIT COUNTY
~,DILHR TRANSFER/RENEWAL UNIFORM PERMIT #
(PLB 67-T)
PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER:
8'- a 9 -94 .5-3v-96
PROPERTY LOCATION: CITY:
VILI AGE:
wN o udsOnJ
%,S Z ,T,2 N,R E (or W o
LOT NUMBER: JBLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR L, MARK:
% O
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: SIGNATURE: NAME: PHONE NUMBER:
ADDRESS: PHONE NUMBER: ADDRESS:
I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
property.
PLUMBER'S SIG TUBE: P%" OUS PLUMBER'S NAME (IF CHANGED):
1PLUkAlER'S AD SS: PREVIOUS PLUMBER'S ADDRESS:
/D DR 1 Poa
MP/MPRSW NUMBER: PHONE NUM ER: MP/MPRSW NUMBER: PHONE NUMBER:
3 (7'l5 ► 38 - D ~ 3 8 ( )
SIGNATURE OF ISSUING AGENT: DA17;24 APPR VED: DISTRIBUTION: Original-County
Q 6 Copy - Bureau of Plumbing
Copy - Owner
-66 16P'7 IL DILHR-S D-63 (R. 5/ Copy - Plumber
Safety and Buildings Division
e.~■~r■r1t SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Nu er
c, c;0 7
X
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Propert Owner Name Property Location
Le., t 1 4' 1/4,4/, 114, 5 a Z/ TV , N, R f E (or)
Property Owner's Mailing Address Lot Number Block Number
2 a max, ` C t 9
City, State Zip Code Phone Number Subdivision Name or CSM Number
( ) r-
C 42 Al -5-1.4 a
11. TYPE F BUILDING: (check one) ❑ State Owned E] City Nearest Road
❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms UILTown OF !v
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
OHO -(3~~'Yd
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise:-Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. §&New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank _Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 [&Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION: S F/r
1- Gallons Per Day 2. Absorp- Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6- System~pElev. hna~ Grade
f Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) d'$'• o X1~7• ad' Elevation
v ed 0' d(' o- t-Ql. o Feet - eet
VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank d C C .,cf ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber F-9-d I ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: No Stamps) VVIO/MPRSWNo.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
1 .0 . 4 ,d ' aS~OC
IX. C UNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing A nt Sign a (No Sta ps
(Aroved surcharge Fee)
pp ❑ Owner Given initial 11 ¢J~
Adverse Determination 6
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) - DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
counter prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
Vl. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot, plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION / Z•
Labor and Human Relations Page ! of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
V
n
Include, but not limited to: vertical and horizontal reference point (BM), direction and S T ewe k
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all Information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location O
T I'm ~tQ Y pos""V Govt. Lot s~ 1/4 4)E/4,S 2 y T )-f N,R / E (or(o
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
440 3A TT-- Sq SUNQfvlrE'
City State Zip Code Phone Number
1 I V PSD El W f' S y0~~0 (7!S ) 3 0 ~1a7 City ❑ Village Town Nearest
it Y,0UN6T
L!7 New Construction Use: esidential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: /V/,P = ~o T R C Fi c Eti11~
Code derived daily flow 4 gpd Recommended design loading rate Nlk bed, gpdfft2 •
t" trench, gpd/1`12
Absorption area required bed, ft2 -75 trench, ft2 N /
Maximum design loading rate bed, gpd/fl2 ' trench, gpd/ft2
Recommended infiltration surface elevations s-~ D 'TES - S.,r.~
N ~ 3 ft (as referred to site plan benchmark)
Additional design/site consi tions ~sE ~ipU~~ McAJ44eS ' w/ D/PDp BO)C I STie~B U T/~~
Parent material ✓C' CS 5 UP_ /'cz- k, A P_ 1) T- Flood plain elevation, if applicable ~ -ft
S = Suitable for system Conv tional Mound In-Grown Pressure AT Grade System in Fill Holding Tank
U = Unsuitable for system Lb s ❑ u ❑ S gru S ❑ u 1:1 s u
❑ s
I ❑ S 2<1 Fil~e'
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
s o 3/ s// 1f S/& navf e S , ~r ,G
-16 10 V 31- S~/ fshk f4 es ~f . Z ' . 3
Ground l0 Y't vlel Z4-hs' 4 /YN
elev.
1~ If 54e- yo~e
Depth to JS iLN 7 ,
limiting
factor
9.&4.in. ,
Remarks:
Boring #
' I
i
Ground
elev.
ft.
Depth to bl AL
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
o b" r ~I t-A 1` i c~,?- 7l✓ 38~ '8/85
Address Date CST Numhar
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground
elev.
ft. '
Depth to
limiting
factor
in. '
Remarks:
Boring #
Ground
elev.
n. '
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots D
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground *`"t
elev. a J '
n.
Depth to
limiting
factor
in. Remarks:
RRnW-R33o IR_ OFAM
30
13M FOL)-A+0 Tv p c F
r` P ELv, - / cs o , o
2`I
66 can O L
l3 Z Sy~
s 3 po
i i I~aion l _'o go
f3s ~ i ~
3 I
1
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L b T S 9 S3 o !Z'_ se 7-
y I s 70 I Top o f 3jy
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(/#VS67- 7-e,57- 466,,4 )
Wisconsin Department of Industry, SOIL AND SITE EVALUATION Z
Labor and Human Relations Page / of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and STi G.~O/
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
1110 AP4(5-aetl Govt. Lot :5:~ 1/4 NE 1/4,S Z T 2-f N,R E ( W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
City State Zip Code Phone Number Nearest Road
44-ILI W/S. ( ;715- )3,P4 ❑ City ❑ Village Town JIPP
New Construction Use: [2 esidential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: /V 7- A0QW'0M 44E~'iV &,0
Code derived daily flow gpd Recommended design loading rate NI, bed, gpd/ft2 trench, gpd/ft2
Absorption area required N/k bed, ft 2 tovo trench, ~ft2 Maximum design loading rate bed, gpd/fl2~~trench, gpd/ft2
Recommended infiltration surface elevation(s) P p ft (as referred to site plan benchmark)
Additional design/site considerations 7-ISS,5 9~D~ ORES ~D~ GU,pUEJ) Td°A.ut4L S O.cI S/off ,
Parent material SC S Sy - /9 veP k"r- 1074' Flood plain elevation, if applicable ft
S = Suitable for system ~Conventional Mound in-Ground Pressure AT-Grade System in Fill Holding Tank
I ❑ S LJ U Ea S[] U El S L'_T U ❑ S E5 ~ ❑ S
U = Unsuitable for system C 5❑ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/1`12
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
LA 104 313 -51 2f 5-h& &4
917 log 3141 S 2 4"
SfJ,t ew-f•e 2 S 2 ✓'F , S Grou e ev. nd 3 z~ 7, SYR %/G . S O. S GQ~ - R
3 ft. ;
Depth to
limiting
factor
4,6 in. L 1- -1
Remarks:
Boring #
/ o /D lt94e 313 Si/ 3
Ground _0 .7'57Vie 3X66 67/ 2 T SDk M^"Fk'- C Gc/ / Ce
elO ffi~j/iIZA~L°v /
10~ , ft p.
Depth to
limiting
factor
V_in. Remarks:
e11
(V ~
o
N
W
M ~
v\ t.
t
Z
~ °r 4~ W ry o 0 ~ o
o 1' u
2 J Ilk,
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
ST c,po~'X
Attach complete site plan on paper not less than 8 1/2 x 1 t inches in size. Plan must include, but
not limited to vertical and horizontal reference point (B tion and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and dist
Ar4_ N REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE RJ1
A L IN l INT4
PROPERTY OWNER: PROPERTY LOCATION
~i H 3 /r'/1/P y eosG OVT. LOT SE 1/4 NE 1/4,S2y T 29 N,R /17 E (oN W/
PROPERTY OWNER':S MAILING ADDRESS R z OT fr BLOCK # SUBD. NAME OR CSM #
IyV(e 3120 ST-. :sy SOX-5 9106E
CITY, STATE ZIP CODE PHONE NUMB []CITY []VILLAGE OWN NEAREST ROAD
HUp.5a~ W r. 9q0 r (~~51,3~~ X67 ,~voso,~ You~G- 2D.
(PrNew Construction use [,,."esidential / Numberof bedrooms 'f f [ ] Addition to existing building
[ J Replacement [ J Public or commerdal'-deim' W" ,JL° - Ivor
~-y0 17
o65X 7713
Code derived dail flow yf6 0 9 i 3- Iss N 2 2
y (DD gpd Recommended design loading rate bed, gpd/n trench, gpolft
Absorption area required /4-' A bed, ft2 /00trench, ft2 Maximum design loading rate 1VM bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) _ S-e e 3 It (as referred to site plan benchmark)
Additional design I site considerations U S i TRH S - Gv v t D +S iV E DE1~ ✓ S!o
Parent material $C S 5 9 V3 V 1Z K G f4R0T-" Flood plain elevation, if applicable NIA- ft
S = Suitable for system CONVENT[] U L MOOS ❑ U IN.G []D U ESSURE AT-G EE U SY SYSTEM IN FIL $ HOLDING TANK
U = Unsuitable for system E3153 SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed mach
i 0-3 /0 ,e 2-/2- s,/. >h~e ~t,.f12 S z y s
1 3-~ /o 11A 3/Z 5, i fs6~ t~ CS z~ y S
Ground 3
elev
~r9 fL / -3/ 75 k
Depth to 7,57
limiting
factor
Remarks:
Boring #
Z-Jy o YX 31y" ~s ~f y,2vfl-2-
yR S i~ S I
Ground
elev. S-y 1- 7,5 V 12 13i9,,DED / Ufjp Q S 7 ' 8
~7, &(2- it.
Depth to
limiting
~ fact
Remarks:
CST Name:-Please Print Q p f3 E R T U L Q R t'C U T Phone: 71,,5-- 3
Address: C'STiN 2- y~ L
Signature: _ e-ana Cnnsultants Date: CST Number:
PROPERTY OWNER J 3 RV 5Ctk- SOIL DESCRIPTION REPORT Page? of
PARCEL I.D. tt 25-0 ,v/? /D6-~5`
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou cl ry Roots GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3. o-7 io vie -4- 10,4,K 2fSbk rmvtx CS i .5 .C.-
1 7-13 /a yR 31;L /ate f si4 X72 rS Z f , y , s
Ground .3 3-1G /O q S/ 1~i,•, S~~n C S f S - G
elev.
4S,Wft. - 7, S ye Yl I/ ,w►v f k C`.v
Depth to 3L 7 ' , oO
limiting
factor
Remarks:
Boring #
l V -S /O /re /Of- /f s 6k Mn f,?P, (='.s f , y
vg c( S 1 S~~ ~ir2 cw I v f. s G
Ground
elevb ~G .
Y 7.5 y ~5 ~vyt .wt v-Fj2 c S i
y Z, 0 it.
Depth to
11miting t
factor ~r
Remarks:
Boring #
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER (f///f/_S 4 D0 NkJ A- j~~4,P /TZ k F-
MAILING ADDRESS 1 3 SO a t~.. -64 L I A, C-1 12o S Ma o UT, 17, 5-'Co
PROPERTY ADDRESS oc Q 1/Q u wa "ed
(location o septic system) Please obtain from the Planning Dept.
CITY/STATE Iladse~✓ S YO /6 PROPERTY LOCATION S:gF 1/4, VgF' 1/4, Section , T_2 j N-R /q W
TOWN OF ,lldd se y ST. CROIX COUNTY, WI
SUBDIVISION SGv,~%d9~ ! LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE: S-16 - 9 6
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property (./IriS nQ i Z-A
Location of 20dom opertyS/_= 1/4~~1/4, Section 2 T~_N-R f 9 W
Township Mailing address
Address of site r `5- I,Freo a A IA' a. s • ,J ) 3/
Subdivision name JUit/ic~ I Lot no.
Other homes on property? _ Yes___)~_No
Previous owner of property
Total size of property a2• S2
Total size of parcel 2. 3 2
Date parcel was created 1Q4
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes _)~_No
Volume 117r and Page Number 3;2g as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signatur f Applicant Co-Applica t
Date of Signature Date of Sig ture
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STATE BAR OF WISCONSIN FORM 1 - 1982
543822 WARRANTY DEED
p R► G! T R`S OFFICE
DOCUMENT NO. VOL 1178 ?ArFV8
- ST CROIX CTY., W1
Roc'd for Fecord t
Greenwood Enterprises, Inc. MAY 16 1996 a=
This Deed, made between , r
a Wisconsin corporation at 2.15 P.M
Grantor,
and Chris A. Kopitzke and Donna E. Kopitzke, Register of Deeds
husband and wife as survivorship marital property
Grantee,
W1tnesseth That the said Grantor, for a valuable consideration of one THIS SPACE RESERVED FOR RECORDING DADA
dollar and other good and valuable consideration NAME AND RETURN ADDRESS ~0. 0 0 Gf
conveys to Grantee the following described real estate in St. Croix Rreenwood- Enterpi~-ise5; Inc.
County, State of Wisconsin: 14-r6 Thifrd-St-rL-et O atf
Husison, -44- 54016
.So7~ bb
(Parcel Identification Number)
Lot 59 of the Plat of SunRidge III, filed in the Office of the Register of Deeds
for St. Croix County, Wisconsin, on January 2, 1996 in Volume 6 of Plats,
at Page 46, as Document Number 538046.
This is not homestead property. ,
jj,-4 (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Greenwood Enterprises, Inc
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions and reservations, if any, of record
and will warrant and defend the same.
Fh April 96
Dated this 2 day of , 19
GREEN D ENTERPRIS , NC. GREEN 00 ENTERP , NC.
By: (SEAL) By
(SEAL)
es E. Rusch, its president * Ma SA, is secretary
(SEAL) (SEAL)
* r
AUTHENTICATION ACKNOWLEDGMENT
Signature(x) James E. Rusch, its STATE OF WISCONSIN
ss.
president ST. CROIX
County. 0